Proposed redistricting for liver transplant sharing would negatively impact Georgia and Southeast

Woodruff Health Sciences Center | Oct. 20, 2016

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Janet Christenbury
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jmchris@emory.edu

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Experts say the proposed wider geographic organ distribution will increase the travel time for a donor liver, while driving up costs and decreasing the quality and survival rates of organs.

A proposed redistricting in the regional structure for allocation of liver transplants may have a negative impact on the state of Georgia and the region.

Many patients with liver disease die while on the waitlist for a liver because of an insufficient supply of donor organs. To decrease disparity in waiting times for liver transplantation in the U.S., the United Network for Organ Sharing (UNOS), with the support of the Scientific Registry of Transplant Recipients (SRTR), is promoting a proposal to change liver allocation in an effort to share donor organs more broadly.

However, according to Emory transplant surgeons, the proposal unfairly disadvantages minorities and lower socioeconomic patients in rural areas in the South by sending those much needed organs to the Northeast.

"The proposed redistricting will take organs from the South, which already has multiple barriers to liver disease care for minority, low-income, and rural patients, and send them to the Northeast, which has a much higher rate of listing liver disease patients," says Ray Lynch, MD, assistant professor of surgery in the Division of Transplantation, Emory University School of Medicine. "Shunting organs around the country only satisfies a very narrow definition of resolving a disparity, at the cost of worsening access for populations that are much more broadly recognized as ‘at-risk’ groups."

Experts say the proposed wider geographic organ distribution will also increase the travel time for a donor liver, while driving up costs and decreasing the quality and survival rates of organs. The longer an organ must travel to its recipient, the higher the chance of complications and the greater the length of the recovery period, increasing the costs and lengths of a patient’s hospital stay. These charges will in turn be passed on to payers, further limiting access to transplant.

Currently, the U.S. is divided into 11 regions. Georgia is in Region 3 along with Alabama, Arkansas, Florida, Louisiana, Mississippi and Puerto Rico. Within Region 3, livers are shared across state lines for patients with a MELD (Model of End Stage Liver Disease) score greater than or equal to 35. A MELD score is used to determine a patient’s place on the liver transplant waiting list. A higher MELD score means a higher mortality rate. Because some patients’ disease is poorly reflected by MELD alone, they may be granted an "exception score" to make them competitive for organs. Certain regions, however, grant these exceptions more freely, so that patients’ average scores at transplant may differ greatly between regions.

The current UNOS proposal would change the 11 regions to eight districts, with Georgia in District 1. The new district would expand up the Atlantic Coast and include South Carolina, North Carolina, Virginia, Washington, DC, Maryland, Delaware, New Jersey, New York, Connecticut, Rhode Island, Massachusetts, New Hampshire, Maine, as well as Puerto Rico. Within this district, livers would be shared across state lines for patients with MELD scores equal to or greater than 29. Recipients within 150 miles of the donor hospital would receive three additional MELD points.

Because of the proprietary and incomplete nature of the proposed model, it is not possible to precisely predict the impact on Georgia transplant centers. Because of the lower rate of organ donation in the Northeast, however, Georgia will go from a region of 47.4 million persons averaging 1204 donors per year to one with 91.4 million persons and an average of 1925 donors. This amounts to a 93 percent increase in population, with only a 60 percent increase in the number of donors, according to Lynch.

"Georgia has three busy liver transplant programs (Emory Healthcare, Piedmont Healthcare and Children’s Healthcare of Atlanta), and those programs performed more than 250 liver transplants in 2015, with more than 240 livers donated by organ donors in Georgia," says Thomas Pearson, MD, DPhil, professor of surgery, Division of Transplantation and executive director of the Emory Transplant Center. "The proposal means Georgia patients, who are already at a disadvantage, will wait longer to receive a liver transplant, will be more likely to die on the waitlist, and those making it to transplant will be sicker. Liver transplant programs in Georgia oppose this proposal."

Based on the volume of transplants, the Emory Transplant Center is the leading transplant center in the Southeast, and is the fifth ranked transplant center nationally. In calendar year 2015, the Emory Transplant Center performed 480 transplants, including 141 liver transplants.

For more information about liver transplants in Georgia and the Southeast, visit the Collaboration for Donation Fairness website.